Optimising Transitions of Care and Long-Term Management in Heart Failure: A Scoping Review of Strategies and Models

Abstract Heart failure (HF) remains a major public health challenge, with high mortality, frequent rehospitalisations, and increasing healthcare costs, which underscores the urgent need for strategies to optimise care transitions and long-term management globally. This scoping review aimed to identify and synthesise current approaches to improve continuity of care in patients with HF. Two systematic searches for (1) transitional care and (2) long-term follow-up (period extending beyond post-discharge, typically for ≥ 6 months) were conducted following the PRISMA extension for scoping reviews (PRISMA-ScR) checklist. Searches were carried out in international databases (PubMed/Medline and Scopus) and through manual searches for records published from January 2015 to June 2024, reflecting the contemporary era of HF care. Strategies were screened by two independent reviewers. After merging the searches’ results (transitional care and long-term follow-up) and adding manually identified reports, 118 studies were considered eligible. Of these, those deemed most relevant by the authors (n=73) were synthesised qualitatively in a table and presented narratively. Most of them were published after 2020 (53.4%) in Europe and North America (75.3%). Intervention studies accounted for 32.9% (45.8% randomised controlled trials). In summary, structured discharge planning with close follow-up reduced 30-day rehospitalisation by 20%–50% (50% with early follow-up, 30% with nursing coordination, 20% with a pharmaceutical intervention). One nurse-led programme, including calls and visits, decreased hospitalisation at six weeks from 16.3% to 8.1% (p=0.048) and mortality at nine months from 13.8% to 4.1% (p=0.03). A risk-stratification-based management reduced death or rehospitalisation for cardiovascular events by 12% (HR hazard ratio: 0.88; p=0.04). An intensive programme with education, exercise, and close monitoring lowered rehospitalisation or death by 38% at 30 days and 39% at 90 days. Multidisciplinary HF units, day care hospitals, and home hospitalisation improved adherence and outcomes. Telemedicine and remote monitoring enabled early detection of decompensation. Pharmacist- and nurse-led interventions enhanced medication safety and adherence. Psychosocial and caregiver support improved self-management and quality of life. Despite heterogeneity across healthcare systems and variability in programme designs, the evidence supports coordinated and patient-centred strategies for HF care transitions and long-term follow-up. These approaches reduce mortality and rehospitalisation, enhance patient engagement and quality of life, and provide a sustainable framework for healthcare systems.